Medicine is changing rapidly. Based on over 300 intensive interviews, here is what will occur in medicine shortly including major changes in primary care, new advances in science, changes in the delivery of care and health care reform. Some of the changes will be disruptive and many will be transformational. They are coming; understand them here.

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Former CEO of the University of Maryland Medical Center, author of the books shown above, former senior investigator at the National Cancer Institute; former head of infectious diseases and director of the University of Maryland Greenabaum Cancer Center, Professor of Medicine and Public Policy at the University of Maryland, former chair Board of Governors of NIH Clinical Center, -- along with a life long love of nature and a frequent visitor to Canaan Valley in West Virginia with my wife of 53 years.

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Thursday, May 9, 2013

Lung Cancer Part 3 – Rx with Surgery and/or Radiation

Surgery
has long been the only way to cure lung cancer. If the tumor was discovered
early – a rare occurrence in the past – then resection could remove it totally.
Recently it has been shown that radiation can be used successfully for early
stage disease. And new approaches to radiation therapy result in the ability to
give higher doses to the tumor, limit damage to surrounding normal lung and do
so with relatively few sessions under the machine.

Thus far in this five part series
has been a general discussion of lung cancer facts and figures followed by
controlled enthusiasm about early diagnosis using CT scanning. The treatment of
lung cancer has also progressed dramatically and with early diagnosis as a
result of CT scanning high risk individuals, it is now possible to cure a
larger proportion of patients.

Today an increasing number of
individuals are having their cancer detected early so curative approaches will
become more common. But many if not most lung cancer patients are older and
have either chronic lung disease, heart disease or both, rendering them at
higher risk for surgery. At a minimum the surgeon wants to do as limited a
procedure as possible, using the least invasive approach. Still, not all
patients are good surgical risks.

Despite finding the cancer when it
is still small and with no apparent evidence of spread, many patients still
relapse in a few months or years after surgery. The addition of chemotherapy to
treat microscopic but undetected disease has a resulted in improved cure rates.
The same approach is being used for those treated with radiation of early stage
lung cancer.

Until recently, it was assumed that
only surgical resection could cure small early stage lung cancer. But many
patients are poor surgical candidates due to age, chronic lung disease, heart
disease or other concomitant conditions. The question thus arises, could these
newer approaches to radiation therapy be as effective.Multicenter trials have now demonstrated that
stereotactic body radiation treatment (SBRT) appears equivalent to surgery in
terms of the local control of the tumor in small (<3cm p="" tumors.="">

It is important to understand that
radiation can destroy any cancer if sufficient radiation can be applied. For
many cancers, however, the risk of damage to adjacent normal tissues that are
essential for life (e.g., normal lung) makes it impossible to give the desired
dose. That said, radiation oncology has advanced dramatically in the past
decade and the rate of progress is increasing rapidly. Innovations as a result
of engineering and computer advances along with conceptual advances are making
a dramatic difference. Major advances in radiation therapy mean greater
effectiveness, fewer side effects and less time in treatment.

Newer devices allow stereotactic
treatment not only for stationary tumors but also lung cancers– overcoming the
problem of motion caused by breathing or even heartbeat and blood flow. The
combination of continuous imaging, motion detection and robotic guidance
combine to allow much more effective treatment than in just the very recent past.

Stereotactic body radiation
treatment appears to be a very useful new approach to many otherwise difficult
to treat cancers such as in the lung. It begins with the use of earlier
techniques where the cancer is treated from multiple angles such that the tumor
receives a large dose but the adjacent normal tissues receive much less. Stereotactic
means that the tumor is imaged and the radiation adjusted to directly attack
the cancer and not the normal tissue. A related innovation is to link actual
delivery of radiation with the patient’s breathing parameters (gating). This is
done with an infrared device that observes motion and turns the radiation beam
on and off during the breathing cycle. This can be of great value in lung
cancer because the target is constantly moving. This greatly reduces normal
tissue damage occurring as the lungs move with respiration. It also means that
the cancer gets a higher dose because the physician is less encumbered by a
concern for damaging adjacent normal lung. This is a real improvement as in the
past it was necessary to curtail the ideal dose with the realization that that
dose would cause unacceptable side effects on adjacent normal tissue.

Hypofractionation, that is giving a
much higher dose of radiation per session, with the much greater accuracy of
the stereotaxic approach, means many fewer sessions yet with high effectiveness.
Much SBRT is now done in 3-5 fractions rather than the more typical approach of
multiple, perhaps as many as 45, fractions over as many days or more. Add
robotic guidance based on motion detection and the combination becomes very
powerful. With robotic control of the equipment from outside the treatment
room, this means less time is wasted by the staff moving back and forth to make
adjustments and less time on the table for the patient.

Most radiation today is delivered
by X-rays or electrons (photons). Another approach is to use protons. Proton
beam therapy has the advantage that the proton gives up its energy only when it
hits its intended target – in this case the tumor. It does not continue through
the tumor and damage normal cells on the far side. So it allows for the
delivery of very high doses of radiation to the tumor with minimal side
effects. It follows that proton beam might prove very useful because one can
give a much higher dose without as much fear of adjacent normal tissue damage.
But it is critical to keep in mind that there are no controlled studies showing
superiority of protons over photons and certainly none in lung cancer as of
yet. As a result it is important that the clinical value of proton beam therapy
not be over inflated. The cost of one center runs into the hundreds of millions
of dollars -- which would purchase 20 or more photon linear accelerators.

What is clear is there is a steady
and rapid, advance in the ability to deliver radiation therapy to those with
lung cancers in a more effective and more safe manner, often in much less time
than in the past. The realization that radiation can actually be used to cure
early stage lung cancer is a stunning advance, allowing effective treatment for
those not able to undergo surgery.

In the next of this series will be
a discussion of the dramatic advances in lung cancer treatment with drug
therapy.

1 comment:

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).